Monitoring Cleaning of Surfaces

ABSTRACT

A method for monitoring cleaning of a surface includes applying an amount of transparent indicator material to an area of a surface and measuring the amount of transparent indicator material remaining on the surface. The transparent indicator material may be fixed on the surface by drying and, when a fluorescent material, may be measured through exposure to ultraviolet radiation.

PRIORITY

This patent application is a continuation of and claims priority fromall priority dates of U.S. patent application Ser. No. 11/335,905, filedJan. 19, 2006, and entitled “Monitoring Cleaning of Surfaces” (attorneydocket number 2952/102). As a consequence of this priority claim, thispatent application also claims priority to the U.S. Provisional PatentApplication 60/666,391, filed Mar. 30, 2005, and entitled “MonitoringCleaning of Surfaces.” The disclosures of each of these applications areincorporated herein by reference in their entirety.

RELATED UNITED STATES PATENT APPLICATIONS

This patent application is related to the following co-pending U.S.patent applications:

U.S. patent application Ser. No. 12/255,304, entitled, “MonitoringCleaning of Surfaces,” naming Philip C. Carling as inventor, filed onOct. 21, 2008, and assigned attorney docket No. 2952/103, the disclosureof which is incorporated herein, in its entirety, by reference.

U.S. patent application No. ______, entitled, “Monitoring Cleaning ofSurfaces,” naming Philip C. Carling as inventor, filed on even dateherewith, and assigned attorney docket No. 2952/104, the disclosure ofwhich is incorporated herein, in its entirety, by reference.

TECHNICAL FIELD

The present invention relates to monitoring cleaning of surfaces, and,more particularly, to monitoring cleaning of surfaces in health careenvironments.

BACKGROUND

Although environmental cleaning and disinfecting practices have become acornerstone of patient care, assessment of actual compliance with suchprocedures has not been reported. During the past decade controlling andlimiting the spread of health care associated pathogens has become oneof the most challenging and aspects of health care epidemiology.Unfortunately the continuing escalation of infections with thesepathogens has led to more than 1.5 million people developing resistanthospital acquired, i.e., nosocomial, infections in the U.S. annually.Despite enhancement of hand hygiene through the development of userfriendly alcohol based hand cleansers, the manner in which they are usedand the difficulty achieving appropriate compliance with their usepotentially limit their effectiveness.

Three pathogens posing significant nosocomial problems are MRSA(Methicillin Resistant Staphylococcus aureus), VRE (Vancomycin ResistantEnterococcus), and Clostridium difficile (C difficile). Their importancederives from a combination of resistance to presently availabletreatments and an ability to rapidly spread extensively in theenvironment around hospitalized patients. MRSA is present in woundinfections, as associated with bed sores and catheters. VRE is presentin bowel and urinary tract infections. C difficile is also present inbowel infections and presents as severe diarrhea. For each of thesepathogens, control with present antibiotics is problematical, if notimpossible.

Although screening based isolation practices have been advocated tolimit the transmission of MRSA and VRE, there are logistical issues andconcerns about the practical application and cost effectiveness of suchpractices. Reliance on such practices may alter the epidemiology but notthe incidence of health care associated infections. Additionally,outbreak persistence as well as significant environmental contaminationoccurs despite patients being on isolation for VRE and MRSA as well asfor patients who are asymptomatically colonized with C. difficile forwhich screening is not feasible. These programmatic as well as pathogenbased issues clearly have limited the effectiveness of current as wellas proposed isolation practices.

Enhancement of existing cleaning and disinfection practices deservesfurther consideration and evaluation. Although it is not currentlyfeasible to define the independent role of the hospital environment inthe transmission of health care associated pathogens except in isolatedinvestigations, numerous studies over the past twenty years haveconfirmed the frequent contamination (FIG. 1) of many surfaces in thenear patient environment (FIG. 2) with hospital associated pathogensable to survive on inanimate surfaces for weeks to months (FIG. 3).

With respect to individual pathogens, it has been found that high ratesof environmental contamination with C. difficile have been associatedboth with symptomatic as well as asymptomatic patients. Directevaluation of the role of environmental contamination in thetransmission of C. difficile found a strong correlation with theintensity of environmental contamination, and outbreaks of C. difficileinfection have been successfully terminated by enhancedcleaning/disinfecting activities.

The role of environmental contamination in transmission of VRE has beendocumented. Recent studies have confirmed the frequency of environmentalcontamination, shown to be highly correlated with the number of bodysites colonized as well as with the intensity of gastrointestinal tractcolonization. Furthermore the ease with which gloved hands can becomecontaminated by limited contact with a colonized patient's bed rail andbedside table the rapid recontamination of surfaces in the near patientenvironment with VRE despite effective daily cleaning even in theabsence of diarrhea as well as the termination of a VRE outbreak in anICU through enhanced cleaning activities support the likely importanceof the environment in the epidemiology of VRE.

MRSA is frequently found in the environment of both colonized andinfected patients and colonized health care workers. The pathogen can betransmitted by the gloves of health care providers and increases inconcentration in the stool of colonized patients receiving broadspectrum antibiotics. Consequently, it is likely that environmentalcontamination plays a role in the spread of MRSA. In addition, DNAtyping in three studies has supported the likely importance ofenvironmental reservoirs in colonal MRSA outbreaks in hospitals lastingfrom three months to five years.

These and similar observations confirm the longstanding belief thatenvironmental cleaning/disinfecting activities are important inproviding an optimally safe environment for patients and have led to thedevelopment of specific guidelines for environmental infection controlin health care facilities. Environmental disinfecting does work.Materials such as phenolic compounds, quartinary ammonium compounds,chloride disinfectants, and formaldehyde can kill a wide range ofmicrobial pathogens, work rapidly, and work effectively in clinicalsettings as shown in FIG. 4.

In 2002, the Centers of Disease Control (CDC) recommended that hospitals“thoroughly clean and disinfect environmental medical equipment surfaceson a regular basis”. Similarly, the Society for Health Care Epidemiologyof America's position paper regarding enhanced interventions to controlthe spread of resistant Staphylococcus aureus and Enterococcusrecommended that hospitals “ensure” that their institutional methods ofdisinfecting surfaces be shown to be “adequate”. In 2003, the NationalHealth Service of Great Britain specifically recommended that “cleaningand disinfecting programmes and protocols for environmental surfaces inpatient care areas should be defined”.

Most recently the draft guidelines for isolation precautions developedby the CDC in 2004 emphasize the importance of environmental cleaningand disinfection activities. Draft guidelines for isolation precautionsdeveloped by the CDC emphasize the importance of environmental cleaningand disinfection activities. Although these guidelines specificallystate that hospitals “ensure compliance by housekeeping staff withcleaning and disinfecting procedures” and “insure consistent cleaningand disinfection of surfaces in close proximity to the patient andlikely to be touched by the patient and health care worker”, theyprovide no directives regarding the means by which hospitals are toassist their ability to comply with or “insure” the effectiveness ofsuch activities prospectively.

In a similar manner the Joint Commission for Health Care Accreditation2004 standard states “hospitals are expected to develop standards tomeasure staff and hospital performance in managing and improving theenvironment of care” without defining what specific resources should beutilized to carry out such activities.

In view of the above, there is a need for a non-microbiologicalmethodology to evaluate the thoroughness with which housekeepingactivities are carried out in hospitals.

SUMMARY OF THE INVENTION

In accordance with one aspect of the invention, a method for monitoringcleaning of a surface includes applying an amount of transparentindicator material to an area of a surface and measuring the amountremaining on the surface. The transparent indicator material may befixed to the area of the surface, as by drying. The transparentindicator material may be a fluorescent material and measuring theamount of remaining on the surface may include exposing the area toultraviolet radiation.

Some embodiments may include one or more opportunities for reducing theamount of the transparent indicator material whose location may beunknown to the receiver of the opportunity. Reducing the amount may be apart of cleaning the surface. The opportunity to reduce the amount oftransparent indicator material may be suspended at the expiration of aperiod of time following initiation, where the period may be a day orless, between a day and a week, or between a week and a month.

In accordance with another aspect of the invention, a composition formonitoring cleaning of a surface includes a carrier, a transparentindicator soluble in the carrier, a transparent source of adherence tothe surface soluble in the carrier, and a surfactant. In certainembodiments, the carrier may be soluble in water and the carrier may bea detergent. In other embodiments the transparent indicator may befluorescent under ultraviolet radiation. In additional embodiments, thetransparent source of adherence may be a natural glue such as methylcellulose.

In accordance with a further aspect of the invention, a method forcontrol of nosocomial pathogens includes evaluating a cleaning programfor a patient-care environment within a facility, enhancing the cleaningprogram for the patient care environment, and comparing the enhancedcleaning program with at least one other cleaning program. In certainembodiments, evaluating a cleaning program may include training withmonitoring surfaces, collecting pre-intervention data, and comparingcontrol within the facility.

In other embodiments, enhancing the cleaning program may includecollecting site-specific demographic data, providing education toadministrative leadership, senior hospital administration andenvironmental services staff, implementing a targeted cleaning anddisinfection program, evaluating an initial intervention program,obtaining feedback of pre and post intervention results, and assistingwith a presentation to the Joint Commission on Accreditation ofHealthcare Organizations (JCAHO).

In additional embodiments, comparing the cleaning program may includecomparing cleaning within the facility with cleaning within at least oneother facility.

BRIEF DESCRIPTION OF THE DRAWINGS

The foregoing features of the invention will be more readily understoodby reference to the following detailed description, taken with referenceto the accompanying drawings, in which:

FIG. 1 illustrates frequency of contamination of common hospital roomlocations by three pathogens.

FIG. 2 illustrates the percentage of contamination of hospital surfacesby the pathogens of FIG. 1.

FIG. 3 illustrates survival of pathogens on inanimate surfaces.

FIG. 4 illustrates a microbiologic evaluation of patient roomcontamination and disinfection.

FIG. 5 illustrates the contents of a typical hospital room.

FIG. 6 illustrates typical locations of targets within a hospital room.

FIG. 7 illustrates a target located on a toilet handle.

FIG. 8 illustrates a dispenser of a composition containing transparentindicator material.

FIG. 9 illustrates a source of ultraviolet radiation.

FIGS. 10A and 10B illustrate detection of a transparent indicatormaterial using a source of ultraviolet radiation.

FIG. 11 illustrates a method for pre-intervention data collection.

FIG. 12 illustrates results of monitoring the cleaning activities ofthree hospitals.

FIG. 13 illustrates results of monitoring of a toilet area of a hospitalroom.

FIG. 14 illustrates results of monitoring of a patient area of ahospital room.

FIG. 15 illustrates a method for control of nosocomial pathogens.

DETAILED DESCRIPTION OF SPECIFIC EMBODIMENTS

Definitions. As used in this description and the accompanying claims,the following terms shall have the meanings indicated, unless thecontext otherwise requires:

Terminal cleaning refers to cleaning of a hospital room followingdeparture of its most recent occupant and prior to the arrival of itsimmediately prospective occupant.

Black light refers to ultraviolet or UV radiation emanating from anultraviolet source.

Transparent refers to capable of transmitting light so that objects andimages beyond can be clearly perceived.

Nosocomial infections are infections arising from and transmitted withina hospital environment.

Cleaning of patient rooms is an ongoing process in a hospital. Eachpatient occupying a room may be subject to pathogens left by a prioroccupant of the room and, in turn, may insert his or her specificpathogens into the room environment. An aim of room cleaning is todecrease the likelihood of the environmental transmission of infectionto an occupant of the room. Some room sites are cleaned daily whileothers are cleaned following patient occupation. Generally, suchcleaning is unsupervised. Correlation of the health of room occupantscould provide an indication of the quality of the cleaning, althoughwith significant effort and with significant delay.

Embodiments of the invention as discussed below illustrate wheremonitoring may provide timely assessment as to whether current cleaningactivities are consistent with control over nosocomial infections andmay have the potential for objectively evaluating cleaning anddisinfecting activities in various health care settings. A nontoxiccomposition containing an indicator material which fluoresces withexposure to a black light is inconspicuous yet may be readily removed byhousekeeping products. Small volumes of composition may beconfidentially applied to target sites in patient rooms followingterminal cleaning and the targets reevaluated following terminalcleaning after several patients have occupied the room.

In an example, evaluation of housekeeping practices at three hospitalshave confirmed high rates of cleaning of traditional sites but poorcleaning of many sites which have significant potential for harboringand transmitting microbial pathogens. An integrated program may identifysuch deficiencies in hospital cleaning and target remediation efforts soas to accelerate reduction in pathogen levels.

FIG. 5 illustrates a typical hospital room 300. Room 300 contains bed310 in association with bed rails 312, bed tray 314, drape 316, anddrape support 318. Patient call box 320 and telephone 322 are locatedproximal to bed 310 and provide communication, where telephone 322 restson table 324. Chair 326 provides additional seating. Sink 328 includingfaucet 330, handles 332, and bedpan flushing device 334 provide acleansing facility. Toilet 342 containing seat 344 and handle 346resides in bathroom 340. Grab bar 348 provides support for patient 305in using the toilet 342. Entry into room 300 and bathroom 340 is throughdoors 350 and 360 respectively via engagement of handle 352 or pushplate 354 for door 350 and of handle 362 or push plate 364 for door 360.Room lights are adjusted by room light switch 370 mounted on room lightswitch plate 372. Bathroom lights are adjusted by bathroom light switch374 mounted on bathroom light switch plate 376.

FIG. 6 illustrates targets for monitoring. These targets correspond toareas of a surface and may be chosen on the basis of the recommendationfrom the CDC that enhanced cleaning activities should be directed at“high touch” objects (HTOs), as well on reports in the literature ofsites reported as being frequently contaminated with hospital associatedpathogens. Such targets may include toilet handle target 446, horizontalsurface target 443 of toilet bowl 342, bedpan flushing device target434, horizontal surface target 431 of the sink 328 adjacent to thefaucet 330, doorknob or door handle targets 452, 462 [or push/grab platetargets 454, 464], toilet area hand hold target 448 immediately adjacentto the toilet 342, bedside table target 424, telephone receiver target422, call button target 420, overbed table target 414, seat target 427of patient chair 326, bedrail target 412 adjacent to the head of the bed310, drape target 416, room light switch target 470, and bathroom lightswitch target 474.

To the degree possible, targets may be placed on the object to bemonitored in an area which is easily accessible for cleaning and inclose proximity to the portion of the object most frequentlycontaminated by patients' and health care workers' hands. As aconsequence of this separation, indicator material placed on the targetsis not subject to removal by the actions of the patient during theinterval between placement of the indicator and the subsequentexamination of the target. In addition, proximity of the targets toareas subject to patient contact makes probable that cleaning of thetargets correlates with cleaning of the patient contact areas. Forexample, FIG. 7 illustrates location of toilet handle target 446 ontoilet handle 346 that is separated from, but in the proximity of,region 510, the area most likely to receive patient contact during useand be contaminated.

FIG. 8 illustrates an applicator 600 for controllably applying acomposition or targeting solution 610 for monitoring cleaning of atarget such as toilet target 446. In FIG. 8, the applicator 600 is aplastic squeeze bottle. The composition 610 may be inconspicuous as bytransparency, environmentally stable, and nontoxic, dry rapidly, bereadily wetted by spray disinfectants, and be easily removed with lightabrasion.

The composition 610 may include a carrier, a transparent indicatorsoluble in the carrier, a transparent source of adherence to the surfacesoluble in the carrier, and a surfactant. The carrier may be abiodegradable anionic or nonionic surfactant containing ammonium laurethsulfate, cocamide mea, cocamidopropyl betaine, ammonium laureth sulfate,sodium lauryl sulfate lauramide DEA, glycerine or sodium pareth-23sulfate. The carrier may, in one embodiment, comprise between 35% and55% percent of the composition. In one embodiment, the carrier maycomprise 45% of the composition.

The transparent indicator may be a transparent ink such as InvisibleInk™ containing fluorescent blue/red water based tracer that isfluorescent under ultraviolet radiation. The transparent indicator, inone embodiment, may comprise between 3% and 5% of the composition. Inone embodiment, the transparent ink may comprise 4% of the composition.

The transparent source of adherence may be a natural glue such as methylcellulose or ethyl cellulose which may be available as powders. Thesource of adherence may, in one embodiment, comprised between 38% and58% of the composition. In one embodiment, the source of adherence maycomprise 48% of the composition.

The transparent surfactant may be polypropylene glycol withp-tert-octylphenoxy polyethoxyethyl alcohol (such as Photo-Flo™). In oneembodiment, the transparent surfactant may comprise between 0.5% and1.5% of the composition. In one embodiment, the transparent surfactantmay comprise 1% of the composition.

Prior to cleaning of a room, the composition or targeting solution maybe deposited on targets such as those indicated in FIG. 6 and fixed tothe surface, as, for example, by being allowed to dry. Since the driedcomposition does not occupy a location likely to encounter abrasion fromdaily activities, its removal may be assumed to be the result ofcleaning activities. When the dried targeting solution is transparent,those engaged in cleaning activities are unaware of target locations.Consequently, they are not biased to clean areas adjacent to the targetsand to avoid non-adjacent areas.

After a single cleaning opportunity or multiple cleaning opportunitiesare presented, cleaning activities may be suspended. That is, furthercleaning in the room may not be permitted until the target areas arescanned. The targets within a room may be then scanned with a deviceable to render visible the dried composition so as to reveal the extentto which the targets have been subjected to cleaning. A target may beconsidered to have been cleaned if the dried composition was removed orclearly disturbed. If the composition contains a material fluorescentunder exposure to ultraviolet radiation, a UV source 700 as shown inFIG. 9 may be held over the target locations to reveal dried compositionnot removed during cleaning. FIG. 10A shows the lack of visibility of atelephone receiver target 422 comprising fluorescent material on atelephone receiver 322 prior to cleaning under ordinary roomillumination and FIG. 10B shows the visibility of the same target 422under ultraviolet illumination from UV source 700, also prior tocleaning. If the transparent fluorescent material is Invisible Ink™(Blacklight World), then an ultraviolet or UV source such as ULTRA9800Ultra Mini Portable Black Light™ (Zigzagalightware) may permitobservation of dried composition residues.

A study of hospital cleaning activities employing the above method,materials, and equipment has revealed deficiencies in cleaning.

Two of the hospitals involved in the study had similar demographics.They were both urban primary and secondary care institutions. Hospital Ahad 136 and hospital B had 115 medical/surgical beds with 15 and 14 bedcombined medical/surgical intensive care units. Although the hospitalshave geographic proximity, their administrative, clinical andhousekeeping staffs are completely independent. Hospital C was a 60 bedacute care short-term rehabilitation hospital.

A targeting solution was used that contained an environmentally stablenontoxic base to which was added a chemical marker as a transparentindicator which fluoresced brightly when exposed to a black light, i.e.ultraviolet light. The targeting solution dried rapidly on surfaces toleave a residue that was inconspicuous, remained environmentally stablefor several weeks, resisted dry abrasion, and was easily removed withmoisture accompanied by minimal abrasion. Small plastic squeeze bottleswere used to dispense approximately 0.2 ml. of solution to standardizedtarget sites.

A group of 12 targets were chosen on the basis of the CDC'srecommendation that enhanced cleaning activities should be directed at“high touch” surfaces [46], as well as sites reported in the previouslycited literature as being frequently contaminated with hospitalassociated pathogens. Such surfaces included toilet handles, thehorizontal surface of toilet bowls, bedpan flushing devices, horizontalsurface of sinks adjacent to a faucet, doorknobs (or push/grab plates),toilet area hand holds immediately adjacent to the toilet, bedsidetables, telephone receivers, call buttons, overbed tables, the seats ofpatient chairs and frequently contacted areas on bedrails. To the degreepossible, the targeting material was placed on the high touch object(HTO) in an area which was easily accessible to cleaning and in closeproximity to that portion of the object most frequently contacted bypatients' and health care workers' hands.

HTOs were confidentially marked after a room had been terminally cleanedfollowing discharge of its occupant. After two to three patients hadoccupied the room and the room was again terminally cleaned, a handheldblack light was used to determine if the marked HTOs in the room hadbeen cleaned. While the marking material was usually completely removedby routine disinfection cleaning, the object was considered cleaned ifthe target material was clearly disturbed. Patient room floors and roomwalls were not evaluated given the limited potential for their servingas a source of transmission of nosocomial pathogens [50]. Statisticaldata analysis was performed using a two tailed Fisher's exact test.

FIG. 11 illustrates a method 800 for pre-intervention data collection.In step 810, rooms for evaluation are chosen randomly withrepresentation from all medical/surgical (M/S) and intensive care (ICU)patient care units. In step 820, HTOs are confidentially marked after aroom had been terminally cleaned following discharge of its occupant. Atthe time a target is marked, a standardized work card (supplied) isdeveloped noting the date, room location and the HTOs marked. In step830, after two to three patients have occupied the room and the room isagain terminally cleaned on two or three occasions, a handheld blacklight is used to determine if the marked HTOs in the room have beencleaned. While the marking material is usually completely removed byroutine disinfection cleaning, an object may be considered cleaned ifthe target material is clearly disturbed. In step 840, the work card isdated and completed on the basis of the observations made. In step 850,once between 50 and 60 rooms are evaluated, Unit Specific Summary Sheets(supplied) are developed to facilitate data analysis.

During the study of periods ranging from one to four months, 60, 54 and43 rooms were evaluated at the three hospitals respectively. Overall 47%of the 1404 HTOs evaluated were found to have been cleaned after severalterminal cleanings. As illustrated in FIG. 12, similar rates of cleaningwere found in each of the three hospitals. As illustrated in FIG. 13 fortoilet areas and FIG. 14 for patient areas, high rates of cleaning,between 80% and 92%, were found for bedside tables, toilet tops, traytables, and sinks. In contrast several HTOs, including bedpan cleaningequipment, patient room and bathroom doorknobs (or door pulls) as wellas toilet handholds were cleaned in between 12.3% and 18% of roomsoverall. The differences found between well cleaned objected (>80%) andpoorly cleaned objects (<20%) in the three hospitals was highlysignificant (P=<0.001). The remaining objects, although more thoroughlycleaned than the group of poorly cleaned objects, were, as a group,still significantly less well cleaned than the objects cleaned greaterthan 80% of the time (mean=88.3% vs. 54.5%, P=<0.0001).

Although the CDC 2003 Guidelines for Environmental Infection Control inHealthcare Facilities recommends “cleaning and disinfection of hightouch surfaces (e.g., doorknobs, bedrails, light switches in and aroundtoilets in patients' rooms) on a more frequent schedule than minimaltouch housekeeping services” (Environmental Services I, E, 3) [45], theaforementioned hospital results indicate that many of these HTOs werenot cleaned as a regular part of terminal room cleaning. In view of theconsistently high frequency of cleaning documented for sinks, toilettops and tray tables, suboptimal cleaning of many HTOs such as bedpancleaners, toilet area handholds and doorknobs may be the result of lackof appreciation for the potential role the latter objects have in thetransmission of nosocomial pathogens rather than ineffective terminaldisinfection cleaning in general.

Two of the least well cleaned HTOs, bedpan cleaners (mean 12.3%, range9% to 20%) and toilet area handholds (mean 17.7%, range 0-50%),represent objects with a high potential for contamination byenvironmentally resilient gastrointestinal colonizing pathogens such asC. difficile, VRE and MRSA. In view of the effectiveness ofdisinfectants for a wide range of pathogens including antibioticresistant bacteria, ineffectiveness of terminal cleaning/disinfectionactivities in substantially eliminating these pathogens from the nearpatient environment in other studies may be the result of suboptimalcleaning.

FIG. 15 illustrates a method for control of nosocomial pathogens usingthe above technique as facilitated by an integrated program 1100tailored to a particular health facility such as a hospital. The programinvolves sequential implementation of a baseline environmentalevaluation system (BEES) 1120, a program enhancement system (PES) 1140,and a program comparison system (PCS) 1160. In the BEES 1120, InfectionControl Practitioner (ICP) is provided and undertakes an assessment ofthe effectiveness of terminal cleaning in approximately 40 randomlychosen patient rooms. Members of the health care facility are made awareof the role of near patient environment in infection prevention and ofthe usefulness of transparent targets. During BEES 1120, site specificdemographic data and pre-intervention data are collected and comparisonsmade within the health care facility or health care institution.

Once the pre-intervention status has been documented in BEES 1120,target monitoring activities are launched in PES 1140. Following anopportunity for administration leadership to comment on the baselineassessment phase, specific training is given to the general facilityadministration and to the environmental services staff beforeimplementation of targeted cleaning and disinfection. Followingevaluation of the initial intervention, structured graphic feedback onthe results of the intervention is provided to administrative,environmental, and nursing services.

Next, in PCS 1160, the program is evaluated and feedback given on anongoing basis, for example, every six months. Part of the feedbackinvolves comparison of the health care facility to other institutions.Recognition may be tended to individuals within the program and to theprogram itself for favorable comparisons with outside institutions.

Although the above discussion disclosed various exemplary embodiments ofthe invention, it should be apparent that those skilled in the art canmake various modifications that will achieve some of the advantages ofthe invention without departing from the true scope of the invention.

1. A method for improving cleaning of an environment comprising: (i)applying a transparent marker to one or more target sites located on oneor more surfaces within an environment, the transparent marker capableof being viewed when exposed to ultraviolet radiation; (ii) determiningif the transparent marker remains on the one or more target sites afterone or more opportunities to clean the one or more surfaces by one ormore environmental services staff members; (iii) establishing aquantitative baseline level of cleanliness for the one or more surfaceswithin the environment, the quantitative baseline level of cleanlinessbeing based, at least in part, upon steps (i) and (ii); (iv) instructingthe one or more environmental services staff members on cleanlinessissues; and (v) evaluating whether the cleanliness of the environmenthas improved after instructing the one or more environmental servicesstaff members by repeating steps (i) and (ii) to establish apost-instruction level of cleanliness and comparing the post-instructionlevel of cleanliness to the quantitative baseline level of cleanliness.2. A method according to claim 1, wherein the one or more surfaces arehigh touch objects.
 3. A method according to claim 1, whereincleanliness issues include at least one selected from the groupconsisting of improved cleaning techniques, results of the quantitativebaseline of cleanliness, locations of areas to be cleaned, andinformation relating to the transmission of pathogens.
 4. A methodaccording to claim 1, wherein the one or more surfaces within theenvironment are located in a single room.
 5. A method according to claim1, wherein the one or more surfaces within the environment are locatedin a plurality of rooms.
 6. A method according to claim 1, furthercomprising: determining a percentage of cleaned surfaces based at leastin part upon whether the transparent marker visibly remains, whenexposed to UV radiation, on each of the one or more surfaces after beingcleaned by one or more environmental services staff.
 7. A methodaccording to claim 1, further comprising categorizing the one or moresurfaces as cleaned or not cleaned after the one or more opportunitiesto clean the one or more surfaces, wherein a surface is categorized asclean if the transparent marker is removed or disturbed.
 8. The methodaccording to claim 1, wherein a source of the ultraviolet radiation is ahandheld device.
 9. The method according to claim 8, wherein thehandheld device is a black light.
 10. The method according to claim 9,wherein the handheld device is a directional UV flashlight.
 11. Themethod according to claim 1, wherein the quantitative baseline level ofcleanliness and the post-instruction level of cleanliness areindications of the presence of pathogens on the one or more surfaces.12. The method according to claim 11, wherein the pathogens include atleast one selected from the group consisting of MRSA, C. difficile, andVRE.
 13. The method according to claim 1, wherein the transparent markerresists dry abrasion.
 14. The method according to claim 1, furthercomprising: performing continuous monitoring of the cleanliness of theenvironment by periodically repeating steps (i) and (ii) andestablishing an updated level of cleanliness.
 15. The method accordingto claim 14 further comprising: re-instructing the one or moreenvironmental services staff members on cleanliness issues and theupdated level of cleanliness.
 16. The method according to claim 1,wherein step (i) is performed prior to terminal cleaning of theenvironment and steps (ii)-(v) are performed after one or more terminalcleanings.
 17. The method according to claim 1, further comprising:generating a list of the one or more target sites, the list includingthe location of the one ore more target sites and when the transparentmarker was applied to the one or more target sites.
 18. The methodaccording to claim 17, wherein determining if the transparent markerremains on the one or more target sites includes using the list todetermine the locations of the one or more target sites.
 19. A methodaccording to claim 1 wherein the transparent marker resists dryabrasion.
 20. A method according to claim 1, wherein the transparentmarker, once applied, may only be removed using at least one of waterand cleaning supplies.
 21. A method for improving cleaning procedurescomprising: (i) applying an amount of transparent indicator material toone or more target sites located on one or more environmental surfaceswithin a first institution; (ii) determining if any of the transparentindicator material remains on the one or more target sites after one ormore opportunities to clean the one or more environmental surfaces byone or more environmental services staff members; (iii) determining apre-intervention level of cleanliness in the first institution, thepre-intervention level of cleanliness being a baseline and based, atleast in part, upon whether transparent indicator material visiblyremains, when exposed to ultraviolet radiation, on the one or moretarget sites; (iv) altering existing cleaning procedures to enhance thefirst institution's cleaning and disinfecting program; (v) determining apost-intervention level of cleanliness in the environment of the firstinstitution by repeating steps (i) and (ii); (vi) comparing thepre-intervention level of cleanliness to the post-intervention level ofcleanliness to determine a change in cleanliness; and (vii) providingfeedback regarding the change in cleanliness to the one or moreenvironmental services staff members.
 22. A method according to claim21, further comprising comparing the pre-intervention andpost-intervention levels of cleanliness with levels of cleanliness of asecond institution.
 23. A method according to claim 21, whereindetermining the pre-intervention level of cleanliness includescollecting pre-intervention data and comparing the pre-intervention datato data collected from other units within the first institution.
 24. Amethod according to claim 21, wherein altering existing cleaningprocedures includes providing training to institutional administrationand the one or more environmental services staff members.
 25. A methodaccording to claim 24, wherein training of institutional administrationand the one or more environmental services staff members includespresenting the pre-intervention level of cleanliness.
 26. A methodaccording to claim 21 further comprising periodically re-evaluating thecleanliness of the first institution.
 27. A method according to claim21, wherein the transparent indicator material is resistant to dryabrasion.
 28. The method according to claim 21, wherein step (i) isperformed prior to terminal cleaning of the environment.
 29. The methodaccording to claim 21, further comprising: generating a list of the oneor more target sites, the list including the location of the one oremore target sites and when the transparent marker was applied to the oneor more target sites.
 30. The method according to claim 29, whereindetermining if the transparent marker remains on the one or more targetsites includes using the list to determine the locations of the one ormore target sites.
 31. The method according to claim 21, wherein asource of the ultraviolet radiation is a directional UV flashlight. 32.A method according to claim 21, wherein the transparent indicatormaterial, once applied, may only be removed using at least one of waterand cleaning supplies.
 33. A method for inspecting the cleanliness of anenvironment and training environmental services staff comprising:pre-marking a plurality of high touch surfaces within an environmentusing an invisible indicator; providing an opportunity for environmentalservices staff to clean the environment; examining the pre-marked hightouch surfaces using a source of ultraviolet radiation to determinewhether the invisible indicator remains on the high touch surface afterproviding the opportunity for environmental services staff to clean theenvironment; identifying high touch surfaces that require additionalcleaning based at least in part on whether the invisible indicatorremains on the high touch surface; and providing training to theenvironmental services staff regarding cleaning of the environment. 34.A method according to claim 33, wherein providing training to theenvironmental services staff includes informing the environmentalservices staff about non-cleaned high touch surfaces.
 35. A methodaccording to claim 33, wherein the environmental services staff isunaware of the pre-marking of the plurality of high touch services. 36.A method according to claim 33, further comprising: confirming that theplurality of high touch surfaces are sufficiently pre-marked prior toproviding the opportunity to clean the environment.
 37. A methodaccording to claim 36, wherein confirming that the plurality of hightouch surfaces are sufficiently pre-marked includes illuminating thepre-marked surface with a UV light.
 38. A method according to claim 33,further comprising training the environmental services staff on propercleaning techniques prior to pre-marking the surfaces.
 39. A methodaccording to claim 38, wherein providing training to the environmentalservices staff includes re-training on proper cleaning techniques.
 40. Amethod according to claim 33, wherein the invisible indicator resistsdry abrasion.
 41. A method according to claim 33, wherein the invisibleindicator may only be removed using at least one of water and cleaningsupplies.
 42. A method for controlling transmission of nosocomialpathogens within an environment of a facility comprising: implementing abaseline environmental evaluation system to provide a pre-interventionlevel of cleanliness within the environment, the pre-intervention levelof cleanliness being determined by applying an amount of transparentindicator material to one or more target sites located on one or moresurfaces within an environment and determining if any of the transparentindicator material remains on the one or more target sites after one ormore opportunities to clean the one or more surfaces by one or moreenvironmental services staff members; implementing a program enhancementsystem, the program enhancement system including training at least oneof facility administration and the one or more environmental servicesstaff members on the baseline level of cleanliness within theenvironment, and providing a post-intervention level of cleanliness; andimplementing a program comparison system, the program comparison systemcomparing the pre-intervention level of cleanliness with thepost-intervention level of cleanliness.
 43. A method according to claim42, wherein implementing the program comparison system further includesre-evaluating the post-intervention level of cleanliness on an ongoingbasis.
 44. A method according to claim 42, wherein implementing theprogram comparison system further includes comparing thepre-intervention level of cleanliness and the post-intervention level ofcleanliness of the environment within the facility with otherfacilities.
 45. A method according to claim 42, wherein implementing thebaseline environmental system includes determining site specificdemographic data and pre-intervention data.
 46. A method according toclaim 42, wherein implementing the program enhancement system includesproviding at least one of facility administration and the one or moreenvironmental services staff members with feedback on the results of thetraining.
 47. A method according to claim 42, wherein thepost-intervention level of cleanliness is determined by applying asecond amount of transparent indicator material to the one or moretarget sites located on the one or more surfaces within the environmentand determining if any of the second amount of transparent indicatormaterial remains on the one or more target site after a second one ormore opportunities to clean the one or more surfaces by the one or moreenvironmental services staff members.
 48. A method according to claim42, wherein the transparent indicator material resists dry abrasion. 49.A method according to claim 42, wherein the transparent indicatormaterial, once applied, may only be removed using at least one of waterand cleaning supplies.